Citation Nr: 1401615 Decision Date: 01/13/14 Archive Date: 01/31/14 DOCKET NO. 07-29 219 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for gout. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for a skin disability. 4. Entitlement to service connection for a left chest cyst. 5. Entitlement to service connection for a sinus disability. 6. Entitlement to service connection for an acquired psychiatric disorder, to include a depressive disorder (claimed as nervous condition). 7. Entitlement to service connection for a back disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Hudson, Counsel INTRODUCTION The Veteran served on active duty from May 1972 to September 1972, and from October 2003 to June 2004. He was in the National Guard from 1972 to 1978, and from 2001 to 2007, during which times he had periods of active duty for training (ACTDUTRA) and inactive duty for training (INACTDUTRA), to include the period of ACDUTRA from September 4, 2005, through September 24, 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2006 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. The issues on appeal were remanded by the Board to the Appeals Management Center (AMC) in April 2011 for additional development. The additional development included clarifying whether the Veteran still wished to have a personal hearing before a decision review officer (DRO) at the RO. The Veteran was sent a letter in August 2012, requesting him to inform the RO as to whether he still wished a DRO hearing. The Veteran did not respond. His representative, in November 2012, requested that the claims file be immediately forwarded to the Board for a decision. Therefore, the Board finds that the hearing request has been withdrawn. The issue of entitlement to service connection for an acquired psychiatric disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. An episode of podagra during service was suspected to be gout, but gout was never confirmed, and there is no lay or medical evidence of a recurrence of the condition since that episode. 2. Hypertension was of service onset. 3. Chronic skin disabilities, variously diagnosed as tinea versicolor, lichen simplex, and hyperpigmented (or hyperchromic) macules, were incurred in active service. 4. A left chest cyst in the left nipple area, present at the time the Veteran filed his claim for service connection, was of service onset. 5. A chronic sinus disability has not been shown. 6. With the resolution of reasonable doubt, arthritis of the low back was shown within a year of the Veteran's discharge from active duty, and cannot be dissociated from current spondylosis and degenerative disc disease. CONCLUSIONS OF LAW 1. Gout was not incurred in or aggravated by service, nor may service incurrence of gouty arthritis be presumed. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 2. Hypertension was incurred during active duty. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2013). 3. Skin disabilities, variously diagnosed as tinea versicolor, lichen simplex, and hyperpigmented (or hyperchromic) macules, were incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303 (2013). 4. A cyst in the left nipple area was incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303 (2013). 5. A sinus disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110 (West 2002 & Supp. 2013); 38 C.F.R. § 3.303 (2013). 6. Spondylosis and degenerative disc disease of the low back are presumed to have been incurred during active duty. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2013) ; 38 C.F.R. § 3.159(b) (2013). In letters dated in July 2005 and August 2006, prior to the initial adjudication of the claims, the RO notified the Veteran of the information necessary to substantiate the service connection claims on appeal, and of his and VA's respective obligations for obtaining specified different types of evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). He was told that the evidence must show a relationship between his current disability and an injury, disease or event in military service. He was advised of various types of lay, medical, and employment evidence that could substantiate his service connection claims. In a separate letter dated in March 2006, he was provided information regarding assigned ratings and effective dates. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Under the VCAA, the VA also has a duty to assist the Veteran by making all reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2013); 38 C.F.R. § 3.159(c) (2013). Service treatment records have been obtained, as have VA treatment records. Pursuant to the Board remand, evidence verifying the Veteran's ACDUTRA and INACDUTRA was obtained. No outstanding evidence has been identified that has not otherwise been obtained. VA examinations were provided in August 2005, August 2012 and September 2012 concerning the issues granted in this decision, and are adequate for that purpose. A VA nexus opinion is not warranted for the issues denied herein because, as discussed below, there is no lay or medical evidence establishing the existence of a disability. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). Further, as to the issues decided herein, the directives in the April 2011 Board remand have been substantially satisfied. See Stegall v. West, 11 Vet. App. 268 (1998) (Board remand instructions are neither optional nor discretionary, and compliance is required); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (the Veteran is entitled to substantial compliance with the Board's remand directives). Thus, the Board finds that all necessary notification and development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or "nexus" between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Service connection for certain chronic diseases, such as arthritis and hypertension, will be rebuttably presumed if manifest to a compensable degree within one year after separation from active service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Moreover, for such diseases, an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. See 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated while performing ACDUTRA. 38 U.S.C.A. §§ 101(22), 106(d), 1110, 1131; 38 C.F.R. § 3.6(c), 3.303. Service connection may be granted for disability resulting from injury incurred in or aggravated while performing INACDUTRA, but not for disease. See 38 U.S.C.A. §§ 101(22)-(24) , 106(d), 1110, 1131; 38 C.F.R. § 3.6(c), (d) , 3.303. The presumptions of service connection and aggravation are not applicable to a period of ACDUTRA. See Smith v. Shinseki, 24 Vet. App. 40 (2010). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Daye v. Nicholson, 20 Vet. App. 512 (2006). Under the benefit-of-the-doubt rule embodied in 38 U.S.C.A. § 5107(b), in order for a claimant to prevail, there need not be a preponderance of the evidence in the veteran's favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1994). Lay evidence may be competent and sufficient to establish a diagnosis of a condition in the following circumstances: (1) when the condition is simple, such as a broken leg, as opposed to when the condition is more complex, such as a form of cancer; (2) when the layperson is reporting a contemporaneous medical diagnosis, or; (3) when lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay persons can also provide an eye-witness account of an individual's visible symptoms. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). Gout Service treatment records pertaining to the Veteran's active duty show that on May 3, 2004, the Veteran was seen complaining that the previous night he had developed severe pain in the first toe area of the right foot. He went to the emergency room and gouty attack was diagnosed. On examination, the right first metatarsophalangeal (MTP) joint area was exquisitely tender with mild to moderate swelling. The assessment was podagra, and he was to have a uric acid test to rule out hyperuricemia. The laboratory study showed an elevated uric acid level of 7.3, with the normal range noted to be 2.6 - 7.2. A sick slip dated May 3, 2004, noted a diagnosis of podagra, rule out hyperuricemia, noting complaints of right leg pain. On May 11, 2004, he was seen for follow-up. His right foot pain had improved. The assessment was status post podagra, and elevated uric acid, rule out gout. However, on his post-deployment medical assessment dated May 24, 2004, approximately two weeks later, he denied having, or having had, "swollen, stiff or painful joints." The Veteran was afforded a VA general medical examination in August 2005. His service treatment records were reviewed, from which it was noted that he was treated for gouty arthritis in the right big toe during service in May 2004. Examination did not reveal any positive findings concerning the foot. A physician appended a note to this examination report in September 2006, stating that the musculoskeletal examination had been negative, and that diagnosis of gout or gouty arthritis was not documented on the VA examination. No additional evidence, lay or medical, has been received concerning this issue. Thus, there is no evidence of an episode of gout, or even podagra, since the in-service incident. Podagra is "gouty pain in the great toe." DORLAND'S ILLUSTRATED MEDICAL DICTIONALRY 1742 (30th ed, 2003). A diagnosis of gout was suspected, but not confirmed, during service. He had an episode of podagra in May 2004. He had an elevated uric acid level at that time of 7.3, with the normal range ending at 7.2. His symptoms resolved, and he did not mention any on the separation medical assessment about 2 weeks thereafter. The Veteran has not stated that he has had any episode of gout since the episode in service, nor has he claimed continuity of symptomatology. Further, there is no subsequent medical evidence of pertinent symptomatology. In view of these factors, the claim must be denied. In reaching this determination, the Board is mindful that all reasonable doubt is to be resolved in the Veteran's favor. However, the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107(b); see Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hypertension Hypertension was not shown during any period of active duty. However, VA treatment records show numerous instances of high blood pressure reading during the year following his discharge from active duty in June 2004, and he was placed on medication to control his blood pressure during that year. In this regard, in October 2004, blood pressure readings of 146/83 and 142/82 were obtained, and a diagnosis of rule out high blood pressure was made. In November 2004, the Veteran's blood pressure was measured at 161/88 and 150/88. It was 168/94 in the right arm and 155/83 in the left arm later that month. By February 2005, hypertension was noted as a diagnosis. Service treatment records show that on an initial medical review, in conjunction with an annual medical certificate, dated June 11, 2005, the Veteran reported that since his last examination, he had begun taking medication for high blood pressure. The reviewer noted that further evaluation was required. Thus, within a year of his discharge from active duty in June 2005, he was noted to be taking medication for high blood pressure. In July 2005, he was seen with a history of high blood pressure. His blood pressure was 157/82 on examination, and the assessment was high blood pressure, uncontrolled, with medication to be changed due to decreased libido with atenolol. On a VA examination in August 2005, the Veteran reported post-service episodes of high blood pressure since July 2004. Upon physical assessment, the Veteran's blood pressure was 140/90, 140/85, and 145/90. On a service department examination in October 2005, the Veteran's blood pressure was 173/79, and a diagnosis of arterial hypertension was noted. VA records show that in November 2005, his blood pressure was 180/90, and he has continued to be treated for hypertension. In June 2006, a blood pressure reading of 161/84 was obtained, and in September 2006, his blood pressure was noted to be 160/105. On a VA examination in September 2012, the examiner reported a diagnosis of hypertension, which had been initially diagnosed in November 2004. The examiner noted that readings obtained in August 2012 had been 152/92; 160/86; and 165/91. The examiner concluded that it was at least as likely as not that hypertension was incurred in service, because of the evidence that he was diagnosed with hypertension several months after returning from his deployment to Kuwait, and he was started on medication at that time. The medical evidence of significantly elevated blood pressure readings obtained within several months of his discharge, followed by a diagnosis of hypertension and the prescription of medication for the condition, all within a year of his discharge from service, support a grant of service connection for hypertension. In this regard, although it is not clear whether the condition was present to a compensable degree during the year after his discharge in June 2004, this is in part because he began taking medication during that period. Once he was prescribed medication to control his blood pressure, any normal readings cannot be considered as evidence that he was normotensive. Moreover, a qualified medical examiner has linked the onset to service, and there is no medical evidence in rebuttal of the examiner's conclusion. Therefore, the Board finds that service connection is warranted for hypertension. In reaching this determination, the benefit-of-the-doubt rule has been applied. 38 U.S.C. § 5107(b); see Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Skin Disability Service treatment records do not show any skin conditions while the Veteran was on active duty. VA treatment records show that in late April 2005, the Veteran complained of an itchy spot on his back, which he had noticed for 3-4 weeks. A dark macular lesion approximately 6 cm long and 3.5 cm wide was observed. It was non tender to touch with no raised borders. Tinea corporis was diagnosed. Service treatment records show that a medical review, in conjunction with an annual medical certificate, dated June 11, 2005, the examining physician noted that the Veteran had a skin condition. VA records show that in June 2005, the Veteran was referred for a dermatology consult for evaluation of an itching skin rash; on examination, he had hyperpigmented macules on the back. The diagnosis was post-inflammatory hyperpigmentation. On the VA examination in August 2005, the Veteran reported that he had had a skin rash on his back since August 2004. He also reported currently experiencing tinea versicolor in different areas of his body, and itching with evidence of dermatitis on his back. Upon physical assessment, tinea versicolor was noted in his abdominal area and macular dark hyperchromic spots were noted on the left side of his back. Diagnoses of hyperchromic macular and tinea versicolor on the left side of the back were rendered. On a VA dermatology consult in November 2006, the Veteran was observed to have hyperpigmented patches on the back and right thigh, and the assessment was chronic lichen simplex. On the VA examination of the skin in September 2012, the examiner reported diagnosis of tinea versicolor, diagnosed in 2005, and hyperpigmented lesion of the back, diagnosed in 2005-2005. The Veteran reported that he had a skin rash on his back which he said had been present since he was in active service in 2004. He said it caused him a lot of itching. He reported that it had started as a small lesion and had continued to increase in size. On examination, the examiner noted that the Veteran had dermatitis on less than 5 percent of the total body area, and less than 5 percent of the total exposed area, define as the face, neck and hands. The examiner concluded that the Veteran's skin conditions were at least as likely as not caused by or a result of his active duty. The rationale was that he complained of his skin rash several months after returning from his last deployment to Kuwait, and it was well known in medical literature that many skin lesions sometimes take months to be obviously visible and give symptoms. In addition, the examiner said that the Veteran was still an active member of the National Guard during the period when he complained to the primary care clinic of the conditions and when he was evaluated by a dermatologist in June 2005. Regarding the latter reason, the examiner appears to be under a misconception concerning active duty versus being a member of the National Guard, in the context of service connection. Significantly, it is not enough to be enrolled in the National Guard; the disability must have been incurred in or aggravated while performing ACDUTRA or INACDUTRA. Nevertheless, the examiner also concluded that the skin conditions at least as likely began during the Veteran's period of active duty, including service in Kuwait. Although the Veteran's statements as to the onset of his skin conditions have not been entirely consistent, the VA examiner in September 2012 found that many skin lesions sometimes take months to be obviously visible and give symptoms. Here, the initial manifestation of a skin condition was on the Veteran's back, which could be easily overlooked for a considerable period of time. Moreover, there is no medical evidence contradicting the examiner's conclusion. Therefore, the Board finds that the evidence is evenly balanced as to this issue. Resolving all reasonable doubt in the Veteran's favor, it is consistent with his statements and the medical opinion that his skin condition(s), variously diagnosed as tinea versicolor, lichen simplex, and/or hyperpigmented (or hyperchromic) macules, began while the Veteran was on active duty from October 2003 to June 2004. In reaching this determination, the benefit-of-the-doubt rule has been applied. 38 U.S.C. § 5107(b); see Ortiz, supra; Gilbert, supra. Left Chest Cyst Service treatment records do not reveal any complaints or abnormal findings pertaining to the left chest or breast during the Veteran's active service, or during a period of ACDUTRA. VA treatment records reflect that in October 2004, on an initial evaluation in a VA primary care clinic, the Veteran complained of a cyst in his left breast which was uncomfortable with touch. Upon physical assessment, the Veteran's left breast nipple was tender and mildly hard but there were no other abnormal findings. X-rays showed no radiographic evidence of cardiopulmonary abnormalities. A diagnosis of rule out breast cyst was made. In December 2004 the Veteran the Veteran complained of a painful lump in the left breast at the nipple site for the past 4 months. There were no new findings with respect to his left breast nipple upon physical assessment. In February 2005, the Veteran was seen for follow-up of his left breast discomfort. He had been referred for a mammogram, which showed gynecomastia and fatty breast. He again complained about his left breast. There once again were no new findings with respect to the Veteran's left breast nipple. Repeat diagnoses of left breast discomfort and atypical chest pain were made. In July 2005, there was no gynecomastia. The Veteran was afforded a VA general medical examination in August 2005. His VA treatment records also were reviewed, from which it was noted that he has been treated for gynecomastia The Veteran also was interviewed. He reported a mass in his left breast found in 2004, and pain with pressure on the left breast nodule. The cyst was noted to be very small and asymptomatic at present. He was diagnosed as having a very small cyst in the left breast area, "resolving in size." On the VA examination in September 2012, the examiner noted diagnoses of left breast cyst, diagnosed in October 2004, and gynecomastia, diagnosed in February 2005. It was noted that he was requesting service connection for a small left nipple cyst. He said that a round the end of 2004, a few months after returning from his deployment to Kuwait, he started to feel some discomfort in his left side nipple and when he checked the area he found a painful cystic like lesion. He had a mammogram done which revealed a cystic lesion. He said he continued to have some discomfort in the area. The examiner concluded that the Veteran's left breast cyst was at least as likely as not related to his active service period. There was evidence that the Veteran had pain and discomfort in his left breast and nipple area since 2-3 moths after he returned from his deployment to Kuwait and as soon as he started treatment at the VA primary care clinic in October 2004, he mentioned the condition. It is not clear that the Veteran currently has a left breast cyst. Absent the current existence of a claimed condition there may be no service connection. Degmetich v. Brown, 104 F.3d 1328 (1997). The examiner in August 2005 described the cyst as "very little," and said it was "resolving in size." The examiner in September 2012 did not report any actual positive findings on examination. No breast or nipple cyst was reported in connection with he Veteran's cardiac bypass surgery in May 2012, or in connection with a cardiac catheterization in December 2012. Nevertheless, the requirement of a current disability is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if no disability is present when the claim is adjudicated. McLain v. Nicholson, 21 Vet. App. 319 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (a recent diagnosis of a disability prior to the claim may constitute current disability). Here, the left breast cyst was still present at the time the Veteran filed his claim in June 2005. Therefore, the requirement of a current disability is met, for purposes of service connection. There is also a medical opinion linking the cyst to service based on the Veteran's statements, which the Board finds consistent with the record as a whole. In this regard, the Veteran states that he first noticed the condition a few months after service, and the examiner stated that based on that history, it was at least as likely as not present in service. The cyst was shown in October 2004, 3-4 months after service. Consequently, the Board finds service connection is warranted for a left breast cyst in the nipple area. In reaching this determination, the benefit-of-the-doubt rule has been applied. 38 U.S.C. § 5107(b); see Ortiz, supra; Gilbert, supra. Sinusitis In his initial claim filed in June 2005, the Veteran reported that he had been treated for sinusitis from November to December, 2003, at the San Juan VAMC. He was on active duty during this period, but service treatment records, including associated VA treatment records, do not show treatment for sinusitis. Even if he was treated for sinusitis at that time, the evidence has not shown sinusitis, or a history thereof, on any subsequent occasion. VA outpatient evaluations in October 2004 and February 2005 were negative for any abnormalities involving the nasal passages, and no history of any such problems was noted. In June 2005, he reported occasional discharge from the nose, but denied sinus disease. Examination at that time was normal. Allergic rhinitis was diagnosed, for which he was to be treated. Subsequent records show Loratadine listed as a medication for allergy, and allergic rhinitis noted on an ongoing "Problem List." However, he has not claimed to have had this condition during service. Moreover, no sinus abnormalities have been identified. On the VA examination in August 2005, the Veteran reported that he had a few episodes of upper respiratory infection treated aboard ship during his period of active duty. He did not report any current symptoms concerning his nasal passages. Examination of the nose and sinuses was entirely normal; there was no evidence of rhinitis or sinusitis at that time, according to the examiner. Thus, the only evidence of sinusitis is the Veteran's June 2005 contention that he was treated for the condition in November and December of 2003. He did not repeat this assertion on his VA examination which was specifically to address the question of service connection two months later, in August 2005. He denied sinus disease on a VA outpatient treatment visit in June 2005. Moreover, there is no evidence, lay or medical, that he has had sinus disease during the appeal period. Absent the current existence of a claimed condition at some point during the pendency of the claim, or shortly before the claim, there may be no service connection. See Degmetich, McLain, Romanowsky, supra. Therefore, the Board finds that the preponderance of the evidence is against the claim for service connection for sinus disease; accordingly, the benefit-of-the-doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C. § 5107(b); see Ortiz, supra; Gilbert, supra. Back On his VA examination in August 2012, the Veteran reported low back pain for almost 8 years, which was not trauma related, although he said that he had a back strain while lifting heavy munitions boxes in 2002 during training duty, and apparently was treated at the San Juan VAMC. The evidence shows that he was on ACDUTRA for two weeks in June 2002. Additionally, service treatment records dated during the Veteran's period of active duty from October 2003 to June 2004 reflect that the Veteran noted "exacerbation or aggravation" of low back pain during his "mission" on an April 2004 Team Member Periodical Medical Evaluation form. VA treatment records reflect that in July 2005, a computerized tomography (CT) scan revealed mild degenerative changes throughout the spine. On the VA examination in August 2005, tenderness in the low back area and chronic back pain were noted. X-rays reportedly showed "only" mild degenerative changes throughout the vertebral spine, and the pertinent diagnosis was chronic low back pain. On a post-Katrina deployment examination in September 2005, the Veteran reported that he had back pain. A VA examination in August 2012, resulted in diagnoses of degenerative disc disease and spondylosis of the lumbar spine. The examiner concluded that the Veteran's back conditions were less likely as not related to active service. The examiner explained that there was no evidence of lower back complaints while on active duty, and, therefore, the degenerative changes found in the lumbosacral spine were most likely age-related and not as a result of event or injury during active service. However, as noted above, there was a complaint of low back pain in April 2004, while the Veteran was on active duty. Moreover, degenerative changes in the spine were noted in July 2005, about 13 months after his discharge from active duty, and he currently has degenerative disc disease and spondylosis. Spondylosis is defined as "degenerative spinal changes due to osteoarthritis." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1780 (31st ed. 2007). The examiner did not attempt to dissociate degenerative disc disease from spondylosis, and the condition would, in any event, rated as a single disability. See 38 C.F.R. § 4.71a, Codes 5235-5243; Mittleider v. West, 11 Vet. App. 181, 182 (1998). Resolving all reasonable doubt in the Veteran's favor, the Board finds that degenerative changes demonstrated 13 months after service were present during the initial post-service year, if not during service itself, and, therefore, service connection is warranted. In reaching this determination, the benefit-of-the-doubt rule has been applied. 38 U.S.C. § 5107(b); see Ortiz, supra; Gilbert, supra. ORDER Service connection for gout is denied. Service connection for hypertension is granted. Service connection for skin disabilities, variously diagnosed as tinea versicolor, lichen simplex, and/or hyperpigmented (or hyperchromic) macules, is granted Service connection for a cyst of the left breast in the nipple area is granted. Service connection for a sinus disability is denied. Service connection for a low back disability, diagnosed as spondylosis and degenerative disc disease, is granted. REMAND The Board finds that the VA psychiatric examination in August 2012, obtained pursuant to the April 2011 Board remand, is inadequate. An Axis I diagnosis of major depressive disorder, recurrent, was rendered. The examiner concluded that it was at least as likely as not that the psychiatric condition was incurred in or caused by service. The examiner explained that there was a direct temporal association between depressive symptom onset and military stressors in 2004 and there was no prior history of mental complaints or conditions. In addition, the examiner opined that musculoskeletal and cardiac conditions were also contributing, predisposing, and perpetuating factors for the major depressive condition. However, the examination report did not identify any specific service "stressors"; indeed, the only stressful event actually described in the report was the death of the Veteran's mother a month prior to the examination. Moreover, it is not clear to which "musculoskeletal and cardiac conditions" the examiner found to be a contributing factor. In this regard, the only such service-connected condition is the low back disability for which service connection is granted in this decision. Service connection is not in effect for his cardiac disease. As noted in the prior remand, service treatment records dated during the Veteran's period of active duty service reveal that he was stationed in Kuwait. He denied having or having had any symptoms during his deployment there in June 2004 Post-Deployment Health Assessments. However, on a VA general medical examination concerning his physical issues in August 2005, he was noted to look depressed. Shortly thereafter, the Veteran was activated for a period of ACDUTRA from September 4, 2005, through September 24, 2005, when he was deployed to New Orleans, Louisiana, for an operation involving hurricane Katrina. An October 2005 service department examination recommended that he have a psychiatric consult for depression secondary to the Katrina mission. The Veteran reported in mid-December 2005 as well as in August 2007 that his symptoms of these disorders began after he returned from deployment in the Persian Gulf War and after deployment to New Orleans following Hurricane Katrina. This evidence was of record at the time of the April 2011 remand, and the examination in August 2012 did not resolve the question concerning a relationship between the Veteran's acquired psychiatric disability and military service. Instead, it raised, but did not satisfactorily answer, a new theory of entitlement, i.e., secondary service connection, which has not elsewhere been raised by the psychiatric treatment records or the Veteran. Given these factors, the Veteran must be afforded a VA psychiatric examination which includes an adequate rationale. The examination also noted that the Veteran said he was awarded Social Security Administration (SSA) disability benefits "last year" for, in part, a psychiatric disability. Records pertaining to this decision must be obtained if available. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010) (VA must request potentially relevant SSA records). Accordingly, the case is REMANDED for the following action: 1. Contact the SSA and request a copy of the Veteran's complete SSA disability benefits file, including all of the associated medical records, in particular, all records obtained in connection with a claim for disability benefits granted in a decision dated in or about 2011. A copy of any response(s) from SSA, to include (if applicable) a negative reply, should be included in the claims file. All records provided by SSA also should be included in the claims file. 2. Thereafter, schedule the Veteran for an appropriate psychiatric VA examination, to determine whether it is at least as likely as not (i.e., there is a 50 percent or more probability) of service onset, or related to any events which occurred in service. In particular, if the examiner finds the condition related to "stressors" which occurred during his period of active duty from October 2003 to June 2004, or during his period of ACDUTRA in September 2005, the stressors and their causal connection to the current acquired psychiatric disability must be described in detail. The examiner should also address whether it is at least as likely as not that any such acquired psychiatric disability was caused or aggravated by the disabilities for which the Board has granted service connection in the above decision, i.e., hypertension, skin condition, low back disability, and left chest cyst for which service connection is granted in this decision. The multi-volume claims folder must be made available to the examiner for review in conjunction with the examination. All indicated studies must be accomplished and the results reviewed prior to the final examination report. Due consideration must be given to the medical evidence and the Veteran's lay statements. A rationale must be provided for the opinion, which explains the basis for all conclusions reached. 4. After assuring compliance with the above development, as well as with any other indicated examinations or other development, review the claim for service connection for an acquired psychiatric disability. If the claim is denied, the Veteran and his representative should be provided with a supplemental statement of the case, and given an opportunity to respond, before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs